https://orcid.org/0000-0001-8270-2580
Figures
Abstract
Background
Rehabilitation and behavior change interventions are commonly used after lumbar surgery to improve recovery, but their effects on physical capacity and physical activity remain unclear. This study aimed to investigate the effectiveness of rehabilitation and behavior change interventions on physical capacity and physical activity behavior in patients following lumbar surgery for degenerative disease.
Methods
EMBASE, MEDLINE, PsycINFO, and CENTRAL were searched from inception to September 2025 and reference lists were hand-searched. Randomized controlled trials assessing rehabilitation or behavior change interventions on physical capacity or physical activity behavior in adults with lumbar degenerative disc disease who underwent lumbar surgery were included. Review author pairs independently extracted data and assessed included studies. Risk of bias was assessed with the Cochrane tool, and study quality with the Grading of Recommendations Assessment, Development and Evaluation classification. Results were pooled using random-effects models and reported as standardized mean differences (SMD) with 95% confidence intervals (CI).
Results
Exercise was more effective than minimal or usual care in improving trunk extension endurance in the immediate term (SMD, 1.54; 95% CI, 0.93–2.16). Supervised exercise outperformed self-directed exercise in improving trunk extension endurance in the immediate term (SMD, 1.28; 95% CI, 0.75–1.81). Psychologically informed rehabilitation was more effective than minimal or usual care in increasing physical activity levels in the intermediate term (SMD, 0.26; 95% CI, 0.02–0.49), but not in the immediate term (SMD, 0.17; 95% CI, −0.14 to 0.49). Physical activity advice did not increase physical activity levels compared to minimal or usual care in the immediate term (SMD, 0.21; 95% CI, −0.13 to 0.55). Prehabilitation was more effective than minimal or usual care in increasing physical activity levels in the intermediate term (SMD, 0.28; 95% CI, 0.03–0.53). Certainty of evidence ranged from low to moderate.
Conclusions
For adults with lumbar degenerative disease who underwent lumbar surgery, exercise, especially supervised programs, improved trunk extension endurance in the immediate term. Psychologically informed rehabilitation and prehabilitation increased physical activity levels in the intermediate term, while physical activity advice showed no benefit. Findings are limited by low certainty of evidence and high risk of bias.
Citation: García-Moreno JM, Adams T, Beynon A, Vlaar Olthuis J, Dombrowski SU, Witherspoon R, et al. (2026) Effects of rehabilitation and behavior change interventions on physical capacity and physical activity behavior following lumbar surgery for degenerative disease: A systematic review and meta-analysis. PLoS One 21(4): e0347420. https://doi.org/10.1371/journal.pone.0347420
Editor: Tadashi Ito, Aichi Prefectural Mikawa Aoitori Medical and Rehabilitation Center for Developmental Disabilities, JAPAN
Received: November 12, 2025; Accepted: April 1, 2026; Published: April 20, 2026
Copyright: © 2026 García-Moreno et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper and its Supporting Information files.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Abbreviations: CI, confidence interval; GRADE, Grading of Recommendations, Assessment, Development and Evaluation; MVPA, moderate-to-vigorous physical activity; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; RCT, randomized controlled trial; SMD, standardized mean difference
Introduction
Lumbar degenerative diseases, such as disc herniation, and lumbar spinal stenosis, are widespread conditions with significant global impact. The prevalence of these conditions ranges from 55.2% to 84.5%, increasing with age [1]. Globally, the annual degenerative lumbar spine disease incidence is 3.6% [2]. These conditions often lead to pain, reduced mobility, and neurological deficits [3], and low back pain remains the leading cause of disability and work absenteeism worldwide [4].
The first treatment option for lumbar degenerative diseases is usually conservative management, which mainly includes rehabilitation and pain management [5]. When conservative treatment fails, surgery becomes the standard treatment [6]. There are different surgical techniques, such as decompression alone or decompression with fusion. While spinal surgery remains an effective option in select patients, it has some drawbacks, including muscle damage, an increased risk of infection, and potential mechanical instability [7].
To improve outcomes and reduce the negative consequences of lumbar surgery, rehabilitation is typically provided before or after the procedure [8]. Traditionally, rehabilitation has focused on recovering physical function and managing pain through specific exercises and education [8]. However, in recent years, behavior change interventions have also been increasingly integrated into rehabilitation programs to address psychological barriers such as kinesiophobia, low self-efficacy, and pain catastrophizing [9]. Despite these developments, rehabilitation practices still vary widely across centers and countries, with notable inconsistencies in patient restrictions, education, and the types of exercises prescribed [8]. This variability complicates the evaluation of rehabilitation outcomes. Although general recommendations for rehabilitation and behavior change interventions can be made based on the type of surgery [8], their effects on aspects such as physical capacity and physical activity behavior remain unclear.
Therefore, this systematic review aimed to investigate the effectiveness of rehabilitation and behavior change interventions on physical capacity and physical activity behavior in adult patients following lumbar surgery for lumbar degenerative disease.
Methods
This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines [10] and was registered with PROSPERO (CRD42020155495). The completed PRISMA checklist is available in S1 Table.
Eligibility criteria
Type of patients.
Studies of adults (≥ 18 years) with lumbar degenerative conditions, such as lumbar spinal stenosis, lumbar foraminal stenosis, lumbar disc protrusion, prolapse or herniation, lumbar spondylosis, lumbar spondylolisthesis, and degenerative disc disease, who underwent lumbar surgery.
Type of interventions.
Studies had to focus on rehabilitation or behavior change interventions provided preoperatively to patients scheduled for lumbar spinal surgery, or within 12 months postoperative. Relevant rehabilitation interventions included physical treatments such as strengthening, stretching, and mobilization exercises, either self-directed or supervised. Behavior change interventions were defined as those using specific techniques (e.g., goal setting, exposure, feedback) to improve physical activity behavior by increasing physical activity levels, including, among others, time spent in moderate-to-vigorous physical activity (MVPA), daily step count, and reducing sedentary time. Since many interventions included multiple components (e.g., supervised exercise that also incorporated a cognitive behavioral intervention), a single trial could contribute to more than one comparison. Comparators included other rehabilitation or behavior change interventions, sham, placebo, or no treatment groups, which could be administered alone or in combination. Any eligible intervention could serve as either the experimental or comparator condition depending on the study design; however, only contrasts in which the intervention and comparator differed in intervention type were included in the systematic review comparisons and the meta-analysis. Detailed definitions of each intervention type are provided in S1 File.
Type of outcome measures.
The included studies had to report data on at least one of the following outcome measures for physical capacity: trunk flexion strength, trunk extension strength, trunk flexion endurance, trunk extension endurance, lower extremity strength, lower extremity endurance, walking capacity, walking speed, balance, or lumbar muscle function, or at least one of the following measures for physical activity behavior: self-reported or objectively measured time spent in MVPA, light physical activity, or sedentary behavior, or the number of daily steps. Reporting of adverse events or other harms was not required for inclusion, but such events were extracted when reported.
Search strategy
A three-step search strategy was implemented. Firstly, an initial exploratory search was performed in EMBASE, and an analysis of the text words contained in the titles, abstracts, and subject descriptors was performed. Second, a search using the keywords and subject terms obtained in step 1 was performed in EMBASE (Elsevier), MEDLINE (Ovid), PsycINFO (EBSCO), and Cochrane CENTRAL; RCTs were isolated using Cochrane’s Highly Sensitive Filter for RCTs and translations thereof [11]. Thirdly, the reference lists in all the selected articles were hand-searched to locate any additional research on this topic. The original search was conducted in November 2019 and subsequently updated in July 2024 and September 2025. A full search strategy for all databases is included in S2 File.
Screening
A two-stage screening process was conducted independently by two review authors. In the first search, pairs of review authors from a panel of four (T.A., N.W., J.H., J.O.) independently performed the screening. For the second and third search, screening was conducted by two review authors (J.H., J.G.). Titles and abstracts were screened to identify studies potentially meeting eligibility criteria. Then, full-text articles were independently assessed for eligibility. Disagreements were resolved through discussion, and when necessary, a third review author (N.W.) was consulted for arbitration.
Data extraction
In all three searches, data extraction was performed independently by two review authors using the same customized form. In the first search, data were extracted by one pair of review authors (T.A., A.B.), while the second and third data extraction was performed by another pair of review authors (J.G. J.O.). Disagreements were resolved through discussion, and a third review author (J.H.) was consulted for resolution. The review authors extracted information on the study population (e.g., age, sex, diagnosis), descriptions of the intervention and comparator, outcome measures, and the main findings of the included trials.
Risk of bias
Risk of bias was assessed independently by two review authors. For the initial search, assessments were conducted by T.A. and A.B., and for the updated search by J.G. and A.B., using the Cochrane Risk of Bias tool [12]. Disagreements were resolved via discussion and arbitration with a third review author (J.H.) when necessary. A study was classified as high risk of bias if it was rated as unclear or high risk in any of the following domains: selection bias, attrition bias, reporting bias, or other bias. The remaining studies were classified as low risk of bias.
Data synthesis and statistical analysis
Outcomes were categorized into four follow-up time points based on the end of the rehabilitation intervention. When this information was not reported, we used the time elapsed since surgery instead. The four categories included immediate (≤2 weeks), short-term (>2 weeks to ≤3 months), intermediate (>3 months to <12 months), and long-term (≥12 months) follow-up. When multiple time points fell within the same category, the time point closest to 1 week for immediate, 8 weeks for short-term, 6 months for intermediate, and 12 months for long-term was selected. Three independent review authors (J.G., J.H., N.W.), two physical therapists and one orthopaedic surgeon, all with expertise in clinical research, assessed the clinical diversity of the included trials, grouping studies only when they were similar across all major aspects, including participant characteristics, interventions, comparators, and outcomes, using clinical judgment. Disagreements were resolved through discussion, and if necessary, a third review author (A.B.), with a background in chiropractic and clinical research, acted as arbitrator.
Two review authors (J.G., J.H.) independently calculated the effect size of each trial using the standardized mean difference (SMD) with Hedges’ g [13], and resolved any discrepancies through discussion. Calculations were performed with Review Manager version 8.14.0 [14] with random-effects models. Statistical significance was defined as p < .05. The baseline-to-posttest differences were estimated for each study, where “posttest” refers to any follow-up time point after the intervention. A meta-analysis was performed when two or more studies shared the same intervention, comparator, outcome, and time frame, and a comparable sample population (e.g., diagnosis, surgical procedure). In trials where both objective and subjective measures were reported for the same outcome, the meta-analysis prioritized the objective data. For articles that did not provide sufficient data (e.g., mean or standard deviation), conversions were made to obtain the necessary information for the analysis, following the guidelines provided by Cochrane [15]. In studies with two intervention groups and one comparator, we applied Cochrane-recommended formulas to combine the intervention groups into a single group when they were sufficiently similar, allowing for appropriate pairwise comparison with the comparator [15]. When necessary, mean values were multiplied by −1 to ensure consistency in the direction of scales before standardization, as recommended by Cochrane [15]. A forest plot was created to visually and numerically represent the individual effects of each study and the average effect size. The magnitude of Hedges’ g was interpreted according to Hedges’ guidelines: a value of 0.2 indicating a small effect, 0.5 a medium effect, and 0.8 a large effect. Additionally, the 95% confidence intervals (CI) for the change scores were calculated, and the prediction intervals were also estimated. The CI was obtained using the Hartung and Knapp method [16] when (a) the between-study variance estimate was greater than 0 and (b) there were more than two study results. In all other cases, we used the Wald-type method, following the recommendations of Cochrane [17]. The tau2 statistic [18], obtained using the Restricted Maximum-Likelihood method [19], and the I2 statistic [20] were used to assess heterogeneity. Analyses of potential publication bias using Egger’s test and funnel plots [21] were planned but not performed due to an insufficient number of studies. Moderator analyses using analysis of variance for categorical variables and meta-regression for continuous variables were also not conducted for the same reason.
Assessment of the certainty of the evidence
We assessed the certainty of the evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) tool [22] and GRADEpro software [23]. Two review authors independently applied the tool and resolved any disagreements through discussion. The certainty of evidence was downgraded from “high” by one level for each of the following limitations: study design or execution (i.e., risk of bias), inconsistency, or imprecision. Specifically, downgrading occurred when (1) more than 50% of patients were from studies not assessed as low risk of bias; (2) I2 values exceeded 50%, indicating inconsistency; or (3) the total sample size was below 400, or when the 95% CI was wide enough that a clinical recommendation would differ depending on whether the upper or lower boundary represented the true effect, indicating imprecision [24]. We did not assess indirectness, as this review focused on a specific population, comparison, and outcome. Additionally, we did not consider publication bias due to the small number of trials included in each analysis [12].
Results
Search results
The search identified 4,363 records, of which 111 were retained after title and abstract screening. After full-text assessment, 32 reports from 30 unique trials involving 2,527 patients were included, with 1,307 patients in the intervention groups and 1,220 patients in the comparator groups. The meta-analysis incorporated 7 trials with a total of 510 patients, including 284 in the intervention groups and 226 in the comparator groups (Fig 1). Reasons for excluding studies at the full-text assessment stage are provided in S2 Table.
Included studies
Among the 32 reports [25–56], two were follow-up reports derived from two original trials [36,40]. The reports were published between 1994 [38] and 2025 [46,49,52–54]. The mean age of the participants ranged from 36.0 [38] to 71.6 years [47]. All reports included both men and women. A total of 27 trials included one intervention group and one comparator group [26–29,31–55], while three trials included two intervention groups and one comparator group [25,30,56]. The diagnoses of the patients were lumbar disc protrusion/prolapse/herniation in 12 trials [25,28–30,32,33,37–39,42,43,56], lumbar degenerative disc disease in seven trials [26,31,34,48,50–52], a combination of degenerative diseases in eight trials [40,41,44–46,49,53–55], lumbar stenosis in two trials [27,47], and lumbar spondylolisthesis in one trial [35,36].
There were diverse rehabilitative interventions and comparators. Exercise, either supervised or self-directed, was the most frequently used intervention and was included in 22 trials [25,27–31,34–39,41,43,44,46,47,49,50,52–54,56]. Other interventions included psychologically-informed rehabilitation in five trials [26,40,44,45,48,55], physical activity advice in five trials [35,36,40,42,44,45,48], and prehabilitation in eight trials [27,40,44,45,47,49,50,54,55]. The most common comparators were minimal or usual care, reported in 18 trials [25–27,29,30,35–37,39–45,47,48,50,55,56], and exercise, either supervised or self-directed, in 16 trials [28,30–34,38,44,46,49,51–54,56].
We categorized intervention vs. comparator contrasts as: exercise versus minimal or usual care in 13 trials across 14 reports [25,27,29,30,35–37,39,41,43,44,47,50,56], supervised exercise versus self-directed exercise in eight trials across eight reports [28,30,31,34,38,44,53,56]; psychologically informed rehabilitation versus minimal or usual care in five trials across six reports [26,40,44,45,48,55]; physical activity advice versus minimal or usual care in five trials across seven reports [35,36,40,42,44,45,48]; and prehabilitation versus minimal or usual care in six trials across seven reports [27,40,44,45,47,50,55]. Seven trials were excluded from the contrasts because both the intervention and comparator groups received the same type of intervention, differing only in intensity or delivery parameters, and therefore did not constitute a conceptually distinct comparison [32,33,46,49,51,52,54]. Details of the contrast tables are included in S3 File.
Trials reported 14 different outcomes. Trunk flexion endurance was included in five trials [25,30,32,53,56]; trunk extension endurance in nine trials [25,29,30,32,36,43,47,53,56]; trunk flexion strength in seven trials [32,34,36,38,41,47,53]; trunk extension strength in nine trials [28,32,34,36,38,39,41,47,53]; lateral trunk flexion strength (right and left) in one trial [41]; lumbar multifidus muscle function in one trial [33]; transversus abdominis activation capacity in one trial [49]; lower extremity endurance in nine trials [26,27,31,32,37,41,43,47,50]; lower extremity strength in one trial [47]; walking capacity in seven trials [40,41,43,45,46,51,53,54]; walking speed in five trials [26,27,31,43,45]; balance in two trials [52,53]; physical activity levels in seven trials [32,35,40,42,44,45,48,55]; and the presence or absence of adverse events in eight trials [33,35,36,43–48]. Detailed information on sample populations, interventions, comparisons, outcomes, and main findings is summarized in Table 1.
Risk of bias and certainty of evidence
Six trials were found to have a low risk of bias [33,35,40,44,45,48,50]. All trials were judge to have performance bias, which was expected given the nature of the interventions evaluated in this review, as blinding of the personnel was not feasible. The selection bias (19 trials) and the selective reporting bias (13 trials) domains were both frequently rated as unclear, mainly due to insufficient reporting of these processes in the articles. The ‘other bias’ domain was also commonly rated as unclear (14 trials), mainly owing to a lack of reporting of sample size justification, small sample sizes, or a lack of a conflict-of-interest statement. Detailed information on risk of bias is available in Figs 2 and 3 and S4 File. The overall certainty of evidence ranged from low to moderate, as presented in S5 File.
Narrative synthesis of study findings
Across the included studies, a wide range of exercise-based, educational, and multimodal interventions were implemented before and after lumbar spine surgery, showing heterogeneous effects on physical capacity and physical activity behavior. Supervised exercise tended to produce greater short-term improvements in trunk strength, endurance, walking capacity, and balance compared to self-directed or usual care, although these effects were not consistent across studies. Psychologically informed rehabilitation and physical activity advice programs occasionally led to improvements in physical activity levels, while prehabilitation generally enhanced pre- and postoperative physical capacity but with mixed results. Overall, the most consistent benefits were observed for supervised, progressive exercise programs. Postoperative interventions were initiated between the first day and three months after surgery, and those started earlier tended to yield better outcomes, although this was not consistent across studies.
Effectiveness of interventions
Exercise versus minimal or usual care.
A total of 12 trials across 13 reports [25,27,29,30,35–37,39,41,43,44,50,56], of which three had a low risk of bias [35,44,50], compared exercise versus minimal or usual care. Several outcomes were reported, including trunk flexion and extension endurance, trunk flexion and extension strength, lateral trunk strength (right and left), walking capacity, walking speed, lower extremity endurance, physical activity levels, and adverse events.
Pooled effects from four trials (n = 258), all rated at high risk of bias [25,30,43,56], provided low-certainty evidence that exercise significantly improves trunk extension endurance compared to minimal or usual care immediately (SMD, 1.54; 95% CI, 0.93–2.16; P = .004) (Fig 4), with between-study heterogeneity estimated at τ² = 0.08. The prediction interval (95% CI, 0.47–2.62) suggested that future studies would also likely demonstrate a benefit, although the magnitude of effect may vary.
Supervised exercise versus self-directed exercise.
A total of eight trials across seven reports [28,30,31,34,38,44,53,56], one with low risk of bias [44], compared supervised exercise versus self-directed exercise on trunk flexion and extension endurance, trunk flexion and extension strength, walking capacity, walking speed, lower extremity endurance, balance, physical activity levels, and adverse events.
Pooled effects from two trials (n = 68) [30,56], both exhibiting high risk of bias, provided low-certainty evidence that supervised exercise improves trunk extension endurance compared to self-directed exercise in the immediate term (SMD, 1.28; 95% CI, 0.75–1.81; P < .00001) (Fig 5) with no heterogeneity (τ² = 0.00). Although the prediction interval (95% CI, 0.75–1.81) suggests statistical consistency across the included studies, this estimate should be interpreted with caution given the small number of trials and their high risk of bias, and future studies may yield different effect sizes.
Psychologically informed rehabilitation versus minimal or usual care.
Five trials across six reports [26,40,44,45,48,55], of which four had a low risk of bias [40,44,45,48,55], compared psychologically informed rehabilitation versus minimal or usual care on walking capacity, walking speed, lower extremity endurance, physical activity levels, and adverse events.
Pooled effects from two trials (n = 157) [48,55], with one trial exhibiting low risk of bias [48], provided low-certainty evidence that psychologically informed rehabilitation does not significantly increase physical activity levels in comparison to minimal or usual care immediately (SMD, 0.17; 95% CI, −0.14 to 0.49; P = .29) (Fig 6) with no heterogeneity (τ² = 0.00). The prediction interval suggested that the effect in future studies would likely fall within the same range as the confidence interval (95% CI, −0.14 to 0.49). At the intermediate time point, pooled effects from three trials (n = 272) [45,48,55], two of which had low risk of bias [45,48], provided low-certainty evidence that psychologically informed rehabilitation significantly increases physical activity levels in comparison to minimal or usual care (SMD, 0.26; 95% CI, 0.02–0.49; P = .04) (Fig 6) with no heterogeneity (τ² = 0.00). The prediction interval (95% CI, 0.02–0.49) suggested that the effect in future studies would likely remain within the same range, although it could be small and of uncertain clinical relevance.
Physical activity advice versus minimal or usual care.
Five trials across seven reports [35,36,40,42,44,45,48], of which five reports were found to have a low risk of bias [35,40,44,45,48], compared physical activity advice versus minimal or usual care on trunk extension endurance, trunk flexion and extension strength, walking capacity, walking speed, physical activity levels, and adverse events.
Pooled effects from two trials (n = 133) [45,48] both with low risk of bias, provided moderate-certainty evidence that physical activity advice does not significantly increase physical activity levels compared to minimal or usual care at the intermediate time point (SMD, 0.21; 95% CI, −0.13 to 0.55; P = .23) (Fig 7), with no heterogeneity (τ² = 0.00). The prediction interval (95% CI, −0.13 to 0.55) suggested that future studies would likely report effects within a similar range.
Prehabilitation versus minimal or usual care.
Six trials across seven reports [27,40,44,45,47,50,55], of which four were found to have a low risk of bias [40,44,45,50,55], compared prehabilitation versus minimal or usual care in trunk extension endurance, trunk flexion and extension strength, walking capacity, walking speed, lower extremity endurance, lower extremity strength, physical activity levels, and adverse events.
Pooled effects from two trials (n = 257) [45,55], with one trial exhibiting low risk of bias [45], provided low-certainty evidence that prehabilitation significantly increases physical activity levels compared to minimal or usual care at the intermediate time point (SMD, 0.28; 95% CI, 0.03–0.53; P = .03) (Fig 8), with no heterogeneity (τ² = 0.00). The prediction interval (95% CI, 0.03–0.53) suggested that the effect in future studies would likely remain within the same range, although it could be small and of uncertain clinical relevance.
Discussion
The findings of this systematic review provide low-to-moderate-certainty evidence that rehabilitation and behavior change interventions may positively affect physical capacity in the immediate term and physical activity behavior in the intermediate term among patients with lumbar degenerative disc disease who have undergone lumbar surgery.
Across the 32 reports included in this review, rehabilitation and behavior change interventions varied substantially in content, timing, and delivery, likely reflecting the absence of international recommendations for structured rehabilitation before or after lumbar spine surgery. Exercise-based programs were the most frequently studied and generally improved physical capacity, particularly trunk strength and endurance, consistent with their emphasis on these components. These findings support the preference for progressive and supervised exercise, which may enhance adherence, ensure adequate intensity, and facilitate safe progression. Psychologically informed rehabilitation interventions showed mixed effects on physical activity behavior. The variability across studies suggests that the duration and intensity of these programs may be critical for achieving meaningful behavioral changes, highlighting the importance of sustained and structured approaches to promote long-term engagement and obtain intermediate-term benefits. Physical activity advice interventions did not demonstrate consistent improvements in physical activity levels, with considerable heterogeneity between studies. Finally, prehabilitation appeared to play a positive role in improving both pre- and postoperative physical capacity, as well as postoperative physical activity levels. These findings suggest that optimizing patients’ functional status before surgery may facilitate recovery and promote earlier return to activity.
In the comparison between exercise and minimal or usual care for improving physical capacity and physical activity behavior, there was only enough research to pool results for trunk extension endurance in the immediate term. In this outcome, exercise interventions consistently resulted in more meaningful benefits than minimal or usual care. The three trials with the largest effect sizes implemented 24-session programs initiated 4–6 weeks postoperative [25,30,56], which may represent a minimum threshold for intensity, frequency, and timing. These programs typically included lumbar and abdominal strengthening, stretching, range of motion, and pelvic tilt exercises. However, the certainty of this evidence remains low due to methodological limitations, including high risk of bias and small sample sizes in the included studies. Despite these issues, the results reinforce the role of structured exercise in rehabilitation. Previous reviews support the superiority of exercise compared to usual care for improving pain and function after disc herniation surgery, with certainty of evidence ranging from very low to moderate [57,58]. In patients with lumbar degenerative conditions, low-certainty evidence supports that exercise improves disability [59]. Similarly, in individuals undergoing lumbar discectomy, one review suggests that exercise may improve lumbar extension strength [60].
In the comparison between supervised exercise and self-directed exercise for improving physical capacity and physical activity behavior, there was only enough research to pool results for trunk extension endurance in the immediate term. For this specific outcome, supervised exercise appeared to result in significantly greater improvements than self-directed exercise. Both trials demonstrated improved results with supervised exercise, which involved 24 sessions over 8 weeks, starting 1 month postoperative [30,56]. This structured approach may contribute to the standardization of intervention intensity, duration, and timing. The supervised exercise programs differed from the self-directed exercise programs in two key aspects: the presence of supervision and the inclusion of lumbar stabilization exercises. Both factors may potentially explain the greater improvements in trunk extension endurance observed with supervised exercise. However, the certainty of this evidence was low due to methodological limitations, such as a high risk of bias and small sample sizes in these studies. Other reviews comparing supervised and self-directed exercise for pain and function yielded mixed results. One review provided very low-certainty evidence suggesting no difference between the interventions in patients undergoing lumbar disc surgery [57], while another study offered low-certainty evidence indicating that supervised exercise reduces pain and disability after lumbar surgery [61]. A further review concluded that the role of supervision in postoperative rehabilitation remains unclear, with conflicting results across studies [62].
In the comparison between psychologically informed rehabilitation and minimal or usual care for improving physical capacity and physical activity behavior, only data on physical activity levels were sufficient to allow pooling of results in the immediate and intermediate term. In the immediate term, no clear differences between interventions were found, as the two included trials reported inconsistent findings [48,55]. Given that the available evidence is limited and inconsistent, with both trials reporting conflicting results, and the prediction interval overlapping the null effect, there is uncertainty about the true effect in future studies. Therefore, additional well-designed trials are needed to clarify the immediate effects of psychologically informed rehabilitation on physical activity levels. However, in the intermediate term, significant effects favored psychologically informed rehabilitation. This delayed benefit may reflect the time needed for psychologically informed strategies to influence physical activity levels, or it may result from insufficient statistical power in the immediate term analysis. The trial reporting non-significant results favoring minimal or usual care implemented a less comprehensive intervention [48], potentially underestimating the true effect. In contrast, the two trials with more favorable results for psychologically informed rehabilitation incorporated cognitive behavioral strategies, encouraged physical activity despite pain, addressed pain-related beliefs, and provided spinal health education, initiated before surgery [45,55]. The consistency of these components across the effective interventions may help establish a standard for such interventions. However, these conclusions are limited by the low-certainty evidence and the small number of trials. Additionally, a meta-analysis showed that cognitive behavioral therapy improves quality of life in patients with lumbar spinal surgery [63].
In the comparison between physical activity advice and minimal or usual care for improving physical capacity and physical activity behavior, only data on physical activity levels were sufficient to allow pooling of results in the intermediate term. In this outcome, no significant differences were found between the interventions. The two included trials reported contradictory results, which may be partly explained by differences in intervention quality and intensity [45,48]. The trial favoring minimal or usual care implemented a less intensive or incomplete intervention [48], whereas the trial favoring physical activity advice provided a more comprehensive approach, initiated before surgery and including cognitive behavioral strategies [45], which may have contributed to the observed benefits. Overall, these findings suggest that physical activity advice may have limited effects on postoperative physical activity levels in this population during the intermediate term, based on moderate-certainty evidence. Given that the available evidence is limited and inconsistent, with both trials reporting conflicting results, and the prediction interval including the null effect, there is uncertainty about the true effect in future studies. Consequently, further well-designed trials are needed to clarify the intermediate effects of physical activity advice on physical activity levels. Evidence from other populations indicates that improvements in physical activity levels may require longer follow-up periods or more intensive interventions. For example, a separate meta-analysis found that wearable activity trackers can promote physical activity engagement and reduce sedentary behavior in hospitalized patients, although it did not report the timing or duration of follow-up [64]. Additionally, a systematic review involving patients with various health conditions reported long-term improvements in physical activity levels after 24 months of physical activity advice interventions, suggesting that longer follow-up may be necessary to detect meaningful changes [65].
In the comparison between prehabilitation and minimal or usual care for improving physical capacity and physical activity behavior, only data on physical activity levels were sufficient to allow pooling of results in the intermediate term. In this analysis, prehabilitation interventions showed better results. The consistency between trials suggests that prehabilitation could play an important role when it incorporates components such as cognitive behavioral strategies, encouragement of physical activity despite pain, addressing pain-related beliefs, and spinal health education in improving physical activity levels [45,55]. However, caution is warranted due to the low-certainty evidence due to the high risk of bias and small number of patients. Evidence from other surgical contexts has shown inconsistent findings. A meta-analysis including only two trials in non-spine surgery populations found no significant benefits of physical activity interventions on physical activity levels when initiated before surgery [66]. Similarly, a small systematic review did not identify clear effects of prehabilitation on physical activity levels in the pre- or postoperative period among patients undergoing various musculoskeletal and visceral surgeries [67].
To our knowledge, no previous systematic reviews or meta-analyses in this population have included the same comparisons between interventions and control groups as those presented in this study, nor have they evaluated the specific outcomes examined in the current study.
This systematic review provides relevant insights for clinicians by synthesizing the current evidence on rehabilitation interventions surrounding lumbar spine surgery. However, the substantial heterogeneity in intervention types, components, timing, and outcomes limits the ability to establish standardized clinical protocols. Rather than prescribing specific interventions, the findings may help inform clinical decision-making by highlighting areas where evidence appears more consistent, such as the potential short-term benefits of supervised and progressive exercise programs for physical capacity outcomes.
Importantly, the findings of this review should be interpreted in the context of individual patient characteristics, preferences, and rehabilitation needs. Given the diversity of interventions and outcomes, different approaches may be appropriate for different patient profiles. For example, psychologically informed rehabilitation may be particularly relevant for patients presenting with maladaptive pain beliefs or fear-avoidance behaviors, whereas structured physical rehabilitation programs may be more suitable for individuals with marked physical deconditioning but more adaptive pain-related beliefs. The differentiated time-point analyses further suggest that improvements in physical activity levels may require longer follow-up periods, whereas changes in physical capacity outcomes, such as trunk extension endurance, may be observed earlier.
At a broader level, while this review may help identify areas where evidence is more consistent, its findings should be interpreted cautiously by policymakers. Important factors such as intervention costs, required professional competencies, availability of specialized personnel, organizational constraints, and feasibility of early postoperative implementation were not assessed and may substantially influence real-world applicability. These considerations highlight the need for future studies that integrate effectiveness outcomes with economic evaluations and implementation-related factors to better inform policy and health system decision-making.
From a patient-centered perspective, the clinical relevance of the outcomes assessed in the included studies should be interpreted with caution. Several commonly reported physical capacity outcomes, such as trunk strength and endurance, are not included in established core outcome sets for low back pain, including those proposed by the International Consortium for Health Outcomes Measurement [68]. Although these measures may reflect improvements in specific physiological capacities targeted by rehabilitation programs, their direct translation into meaningful functional recovery or daily-life participation is uncertain. In contrast, outcomes such as physical activity levels and walking capacity may better reflect patient-relevant improvements, as they are more closely linked to everyday functioning and overall health. The limited and heterogeneous evidence for these outcomes highlights an important gap in the literature and underscores the need for future trials to prioritize patient-relevant outcomes alongside traditional measures of physical capacity.
Future studies should prioritize the design and implementation of high-quality RCTs with minimized risk of bias, following the CONSORT guidelines [69]. Emphasis should be placed on ensuring transparent reporting of randomization and allocation processes, as well as proper blinding of outcome. These trials should also include larger sample sizes to enhance statistical power and improve generalizability. Standardizing outcome measures, including reliable and valid instruments specific to the target population, and objective assessments when possible, would enhance comparability and reduce heterogeneity. For example, trunk extension endurance can be reliably and precisely evaluated using an isokinetic dynamometer [70], while physical activity behavior is best measured objectively through accelerometers rather than relying on subjective questionnaires [71]. Additionally, incorporating multiple time points for outcome assessment is also essential to accurately capture the immediate, short, intermediate, and long-term effects of interventions.
Strengths and limitations
This study has several notable strengths and limitations. Comprehensive manual and electronic searches were conducted, and a priori study protocol registration was completed. Two review authors independently screened the studies, performed data extraction, data synthesis, data analysis, and risk of bias assessment, and evaluated the certainty of the evidence. Furthermore, standard statistical methods were applied, and the most current guidelines for conducting and reporting systematic reviews were followed. Notably, this is the first meta-analysis to include trunk extension endurance and physical activity levels in this patient population, offering novel insights into previously unexamined outcomes. However, there are several limitations to consider. The ability to perform a comprehensive meta-analysis was restricted due to the limited number of available clinical trials. Additionally, the high risk of bias in most of the studies and the low certainty of the evidence reduce the robustness of the study’s conclusions. The considerable heterogeneity observed among the studies and differences in the tools used to measure outcomes hindered the ability to effectively pool the data for meaningful comparisons.
Furthermore, the comparator described as “usual or minimal care” is often not clearly defined in many trials. Additionally, the content of usual care varies considerably across clinics and rehabilitation centers [72], introducing unmeasured confounding and increasing heterogeneity among trials that used “usual or minimal care” as the control group in randomized studies.
Conclusions
In adults with lumbar degenerative disease who have undergone lumbar surgery, exercise appears to be effective in improving lumbar extension endurance in the immediate term, with supervised programs outperforming self-directed approaches. Psychologically informed rehabilitation and prehabilitation interventions increased physical activity levels in the intermediate term, whereas physical activity advice did not. However, study findings should be interpreted with caution due to the low certainty of the evidence and the high risk of bias in many of the included studies. Future research should prioritize the identification of patient-relevant outcomes and clinically meaningful subgroups to better align rehabilitation strategies with patient needs, before advancing to larger, high-quality trials.
Supporting information
S2 File. Search strategies applied to EMBASE, MEDLINE, PsycINFO and CENTRAL.
https://doi.org/10.1371/journal.pone.0347420.s003
(DOCX)
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